Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology)
- PMID: 21249825
- Bookshelf ID: NBK20499
Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology)
Excerpt
While systems thinking enables new and productive approaches to improving patient safety, it brings with it its own conceptual challenges—challenges that, if not recognized and addressed, will both slow our progress and introduce new harm. These challenges require that we learn more about how to apply systems thinking to health care, through answering such questions as: What are the microsystems and macrosystems in health care? How can their performance be measured? How do they interact? What are their vulnerabilities—and strengths? What are the strengths and weaknesses of each component that comprises the system? How can those strengths and weaknesses compensate for each other within the larger system? How can the functions of each component be optimized so that the results of the system are maximized? How can we identify and monitor for unintended consequences? How can we intervene to prevent harm from unintended consequences? Many of these questions are the direct or indirect foci of the articles in this volume on “Concepts and Methodology.”
Sections
- Preface
- Acknowledgments
- Prologue: Systems Thinking and Patient Safety
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Measurement and Taxonomies
- Applying Patient Safety Indicators (PSIs) Across Health Care Systems: Achieving Data Comparability
- Validation of AHRQ's Patient Safety Indicator for Accidental Puncture or Laceration
- Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator
- Patient Safety Research in Medical Group Practices: Measurement and Data Challenges
- Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative
- Taxonomic Guidance for Remedial Actions
- The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization
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Surveillance
- Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency
- Medical Injury Identification Using Hospital Discharge Data
- Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative
- Development and Implementation of The University of Texas Close Call Reporting System
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Medication Safety
- Translating Patient Safety Research into Clinical Practice
- Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting
- Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors
- Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words?
- Methodological Challenges in Describing Medication Dosing Errors in Children
- Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings
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Cognition, Systems, and Risk
- Diagnostic Failure: A Cognitive and Affective Approach
- Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project
- Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding of Daily Work
- Clinical Inertia and Outpatient Medical Errors
- A Conceptual Framework for Studying the Safety of Transitions in Emergency Care
- Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology
- Work System Analysis: The Key to Understanding Health Care Systems
- Observing Nurse Interaction with Infusion Pump Technologies
- Usability Testing and the Relation of Clinical Information Systems to Patient Safety
- Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation
- Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities
- A Model-based Approach to Prioritizing Medical Safety Practices
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Safety Culture and Organizational Issues
- Creating a Culture of Patient Safety through Innovative Hospital Design
- From Science to Service: A Framework for the Transfer of Patient Safety Research into Practice
- Making a Case for Organizational Change in Patient Safety Initiatives
- Organizational Climate of Staff Working Conditions and Safety—An Integrative Model
- A Conceptual Model for Disclosure of Medical Errors
- Peer Reviewers—Volume 2
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